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Wednesday, June 18, 2014

Apical Core

I was looking at an apical core a few weeks ago. The surgeons take these cores at the apex of the heart when they are putting the patient on mechanical heart support. Most of the time there is bizarre cardiac muscle nuclear change from hypertrophy. Fibrosis. Iron accumulation. Amyloid. Pathologists look for different things based on the clinical history we read in the chart. This core was clean as a whistle. No fibrosis, tiny box-shaped nuclei. I looked at the patient age - 20's.

I delved into the chart to read about it - a 20 something year old that needed mechanical heart support? Was this viral? Genetic? The history showed no clue. A previously vitally healthy human being had gone downhill to this moment in just a few weeks. She was a student, a daughter, a musician.

A couple of days later I was rushing to finish my cases to leave early for my daughter's fifth grade graduation. I wanted to do something for her - something simple and sweet and manageable. I walked over to the hospital flower shop to chat with the florist. It was under new management and I enjoyed talking to the young energetic successor to the former manager. I explained to her what I was wanting and she pointed to a small basket of flowers.

"I was thinking more along the lines of a single flower. Something that would be easy to carry and give. Maybe a Gerber daisy?"

Her assistant came out of the back room. "What are the school colors?"

That's a good question. I had to reach. "Green and yellow."

"We have one yellow Gerber left."

As the assistant began to package the flower and tie a beautiful dark green ribbon around it I chatted with the manager. She was asking me about what I did at the hospital. The assistant suddenly joined in.

"Do you ever look at hearts?"

"Yes, actually I have an interest in that area. I see lots of explanted hearts and look at biopsies for rejection of transplanted hearts."

"I am asking because I have a friend in the hospital. It's her daughter. We are very close. I'm wondering if you would have seen her pathology. She was just put on support and is waiting for a transplant."

Oblivious, thinking about my schedule and my daughter and my day, I answered, "Oh yes we look at apical cores for mechanical support all the time. I saw one just the other day."

"Oh I wonder if it was hers? She's young, in her twenties, and we are all praying for her. Do you think you saw it?"

I suddenly put two and two together and became hyper-aware of HIPAA in my head. I told her, "Well, a lot of us look at those and we see them all the time. I doubt it was your friend's, but it could have been."

I turned the conversation back to the manager as she was ringing me up. The assistant became increasingly desperate with her questioning. She seemed to really need to know if I had seen her friend's heart core biopsy. She didn't need to know about it, but her entreaties and interruptions into my conversation with the manager were too much for me. I didn't want to violate HIPAA. I didn't want to give out any information. The manager seemed to feel my pain and supported me. "She is a pathologist. She doesn't know the patients, she just reads the tissue." I recoiled in defense.

"Well, that's not exactly true. I read every patient history. I latch onto the stories. Of course I am reading the information to get a better handle on the tissue, but every clinician adds a new piece of personal information to help me see the patient. I don't meet them, but I feel like I know them - some more than others. I'm just a voyeur, but I'm present."

The manager and I started talking again and I did something I'm not entirely proud of but it seemed like the right thing to do at the time and I am glad in retrospect. To placate the assistant I managed to slip in the 20 something year old's musical area of expertise innocuously into the conversation I was having with the manager. Whatever I said or didn't say worked. She relaxed and smiled and interpreted my silent acknowledgement as some sort of reassurance. Suddenly she said, "I have to show you a picture of my friend's daughter. I just want you to see her, even if you weren't involved in her care."

The manager said, "She's busy and she is in a hurry."

I told her to take her time I would wait. I would love to see her friend's daughter. She pulled up a photo on Facebook on her phone and showed me. I was totally unprepared for my response. She was incredibly beautiful, and suddenly and surprisingly tangible in a way so much of the tissue I see isn't. I had seen a piece of her heart just the other day. I never get to see the patient. I read and read and read but there is never a human face connected to the tissue. My eyes welled up and I choked back a sob.

The manager told her assistant, in a loving but chiding way, "Look what you did you made her cry!"

I replied, "No, it wasn't you. I am a little emotional about my daughter." I looked the assistant straight in the eyes as mine were trying to clear of tears. "Thank you."

2 comments:

Thank you:). It was a very intense experience. I asked the florist about her friend when I went in the other day to get a present for a friend who was about to undergo surgery. She is doing well, but still not out of the woods. She is in my thoughts.

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

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